Provider Network Account Executive II

Responsibilities:

The AE II is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers.  Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations.  AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.  Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products.   Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements.  Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance.  Uses data to develop and implement methods to improve relationship.  Assists in corrective actions required up to and including termination, following Plan policies and procedures.  Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues.  Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department.  Maintains and delivers accurate, timely activity and metric reports as required.  Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.  

An AE II’s accounts/assignments include:

• Those that are most complex, a higher number of multiple  practice locations and multi-specialty practices and multiple providers. 
• A total practice annual pay amount over $1M.
• Those that impact a total member population of a minimum of 5,000 or more.  The appropriate minimum number of member population impact for the AE II level is determined by each Plan according to their business environments.

The AE II is responsible for managing an ongoing Provider Network Management organization project or program.   

Will develop/implement/manage programs and projects that support/impact high dollar and high member provider groups.   

The AE II is responsible for participating or independently developing and implementing Provider Network education programs and materials (both internal and provider targeted) and is assigned to train, mentor and support new AE’s.   The AE II will assist AE I’s in resolving/managing issues with Providers.

Education/ Experience:

• Bachelor’s Degree.
• 3 to 5 years experience in a Provider Services position working with providers.
• 5 to 10 years experience in the managed care/health insurance industry with demonstrated strengths in:  knowledge of Plan policies and procedures related to provider contracting, provider credentialing, provider billing and payment, provider incentive programs and other key State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications;  working independently and managing complex projects and programs both as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.     
• Substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider groups.
• Medicaid experience required.